Wraparound Blog Archives - National Wraparound Initiative (NWI)

Your Voice Needed! How Do We Scale Up Wraparound Without Losing Its Soul?

October 24, 2022 | Eric Bruns

I’d like to hear from you. What do you think?

Please consider responding to this ultra-short survey to help me deliver a message to our colleagues in New Zealand.

Thirty years ago last month, I entered graduate school on a quest. I had spent two years out of college working at a residential facility for youth. I was eager to find a career in which I could shape the policy environment for child and family services so that young people would never unnecessarily be removed from their homes and placed in such institutions.

The people working there were caring and skilled at what they did. But the teenagers they served wanted nothing more than to be home. And not just for a few hours as a reward for getting to “Level 4” on their star chart.

Their caregivers – parents, grandparents, uncles and aunts – wanted them back as well. But they had unmet needs of their own and needed help to be able to maintain them safely in their homes.

I found an opportunity to learn about better ways of working with youth and families from my mentor, John Burchard, Ph.D., at the University of Vermont. During my time in Burlington, I spent two internship years working at Northeastern Family Institute (NFI), home to one of the country’s first Wraparound programs. One year I was a care coordinator, the next I was a therapist.

Like most states, Vermont had a lot of children and teens who had been placed in psychiatric and residential facilities over the years. The state wanted to bring these young people back as well as divert youth from future placements.

Given that placement in those facilities could cost the state tens of thousands of dollars per month, it seemed like a no-brainer that “doing whatever it takes” via community-based Wraparound would be much cheaper. It made good business sense. And, if it was done with quality and maintained safety, it was the right thing to do for families.

How did Vermont and NFI organize Wraparound to “do whatever it takes”?

Our staffing ratios were six families per care coordinator. We also had flex funds – essentially a blank checkbook to pay for whatever was needed in the plan of care.

We could work whatever hours we needed to, and had access to a full-time psychiatrist to help with medication management for our youths. We rotated on the crisis beeper, but only once every two months to make it reasonable and avoid burnout. In group supervision, we shared crisis plans and important information so we could be helpful if we needed to respond to crisis.

We didn’t have too much paperwork. We had our contact log and plans of care and that was about it.

All this was possible because NFI received a bundled “per youth per month” rate for every family it served. Some families required thousands per month at first to address crises, as it paid for intensive in-home service and 20 hours per week of respite care from relatives. But others required only a few hundred per month, as needs were met. In the end, it all evened out and was far cheaper than facility-based care. Families were able to experience people doing “whatever it takes” and staff could just make that happen.

We had fun and felt fulfilled because those system and program conditions made it possible. NFI’s per family rate allowed them to invest in their staff’s career ladder as well as in things we did together to build camaraderie and morale.

We saw families who had previously been wrung out by “the system” succeed and grow hope. Some youth had setbacks, but many began to thrive as their needs were addressed.

Based on evaluations and stories from projects like NFI’s – and the Alaska Youth Initiative, Kaleidoscope in Chicago, and many others – Wraparound has evolved over the past 30 years from a radical idea to a well-researched and widespread best practice that is increasingly listed on national registries of evidence-based practices.

In the United States, Wraparound is now used by behavioral health, education, child welfare, and justice systems in nearly every state to coordinate care for over one hundred thousand youth and families.

Unfortunately, research has also documented many examples where Wraparound is failing. All too often, our Wraparound Evaluation and Research Team finds a lack of adherence to Wraparound principles and bad outcomes for children and families.

We recently did an evaluation of a Wraparound project where we found that only three of 40 youth enrolled in Wraparound that year transitioned positively, such as because they made adequate progress toward their needs. Yes, that is less than 8 percent.

What tends to happen in Wraparound initiatives with such poor outcomes? They do not look anything like the original vision for Wraparound.

Documentation requirements are overwhelming. Flex funds are not available. If they are, paying $100 to register for a camp or after school program can take 10 hours of work to request and approve.

Individualized plans don’t happen because care coordinators are employed by the same agency as therapists, rather than having access to a rich service array of options. Family and youth peer partners’ primary directorate is to generate billable hours.

Of course, I also get to travel across the country and see examples where Wraparound providers and family run organizations have found ways to keep Wraparound’s soul, programs with 80% positive transition rates. Often, it’s at the expense of their leaders’ own mental health, as they fight the quest of managed care to maximize revenue and minimize expenditures at all costs.

Meanwhile, we hear reports of fidelity Wraparound being hard; that its expectations are too high and unrealistic. But this is not Wraparound’s fault. The overlay of managed care and fee for service on Wraparound efforts is based on antiquated approaches to care.

Quality Wraparound is not hard. It simply diverges from decades old traditional mental health models and financing structures that worry more about productivity hours and paperwork than actual support and help.

All this has left many to wonder whether the adoption of Wraparound at large scale by public systems has led it to “lose its soul,” sacrificing its initial spirit of “doing whatever it takes” to help youth with complex needs live and thrive in their homes and communities.

I have been invited by New Zealand’s national Wraparound initiative to present at their “hui” – a Maori word for “big gathering.” In New Zealand, Wraparound has grown from under 100 youths to nearly 600 just in the past few years.

They asked me what I’d like to present on. I said I’d love to try to help assure that, as they grow, their Wraparound efforts don’t “lose their soul.”

Part of that presentation will certainly be lessons learned from our research. As many of you have probably read, we have documented research evidence that using a Care Management Entity (CME) approach to organize and fund Wraparound promotes better fidelity, family satisfaction, and outcomes.

This is because CMEs, when implemented well, use monthly per member rates instead of fee for service, and operate independently from other provider organizations. Both allow for more individualized and tailored care for families. If the rate is adequate, and the rules ideal, the Wraparound provider organization can keep the savings in out-of-home expenditures and invest in new services and supports, retention bonuses for staff, espresso machines and ping pong tables, and happy and fulfilled staff (as I once saw in a trip to Ascent’s offices in Monroe Louisiana).

But looking at financing and policy options is just one way to preserve Wraparound’s soul.

I’d like to hear from you. What do you think?

Please consider responding to this ultra-short survey to help me deliver a message to our colleagues in New Zealand.

The survey has two main questions:

  1. What have you seen that is causing Wraparound to “lose its soul”?
  2. What do we have to do to “keep Wraparound’s soul”?

Knowing the people who subscribe to the NWI newsletter, I fully expect to get an amazing response. We will also be sure to feed back what we hear to everyone in a future newsletter.

Be well and keep doing great work,

Eric

Join Our Team! An Opportunity for Researchers, Graduate Students, and Trainees to Help Grow the Research Base on Wraparound and Systems of Care

September 23, 2022 | NWI

If you follow news and updates from the National Wraparound Initiative, you know that the NWI’s driving purpose is to conduct research on “what works” for youth with complex needs and their families and then translate that knowledge into action in the real world for real youth and families.

Working with the National Wraparound Implementation Center (NWIC) and hundreds of partners across the country, our team at the University of Washington, Portland State University, and the University of Maryland, Baltimore, has conducted rigorous research, gotten federal research grants, developed evaluation and quality assurance measures, and synthesized research on the impact of Wraparound.

As a result, Wraparound is now widely understood to be a research-based practice. Moreover, states and organizations that implement Wraparound have access to a wealth of resources to help their efforts. These include implementation standards, training curricula, coaching tools, and measures of practice fidelity as well as organizational and state supports, just to name a few.

The volume of data being generated from all these measures and tools is immense. That is why we are issuing this call to researchers, students, and trainees to join us in our work.

If you are a graduate student seeking a thesis or dissertation topic, or are a researcher with expertise in child and family service delivery, and wish to take advantage of NWI and NWIC’s wealth of data and partnerships, we want to hear from you! Researchers, post-doctoral fellows, and graduate students who are interested in accessing, analyzing, and writing up or presenting results can reach out by emailing us at wrapeval@uw.edu.

In your email, tell us a little bit about yourself, your skills, and your research interests. Once we hear from you, we will provide you with a survey that will help us better understand whether and how we might provide you with access to relevant datasets, and how we might work together. To help you get started, see the table below to see examples of relevant research questions and datasets that qualified research partners might be able to use.

We hope to hear from you, so we can make the most of the incredible, data-informed movement that is Wraparound systems of care.

Eric Bruns,
Professor and Co-Director, NWI

Janet Walker,
Professor and Co-Director, NWI

Jonathan Olson,
Research Scientist, UW WERT

Kim Estep,
Director of Training, NWIC

Table 1. Wraparound Data Sources, Constructs, and Sample Projects

Data Sources Constructs Measured Sample Projects
Wraparound Fidelity Index – Short Form (WFI-EZ) Wraparound fidelity (based on caregiver, care coordinator, youth, and team member surveys), youth and family satisfaction, youth outcomes, demographics Relations among youth and family characteristics, Wraparound implementation quality, and youth outcomes
Document Assessment and Review Tool (DART) Wraparound fidelity (based on document review), Wraparound processes, clinical and functional outcomes Validation study of the DART; Study of relations among fidelity indicators, Wraparound processes, and clinical and functional outcomes
Team Observation Measure (TOM 2.0) Wraparound fidelity (based on observations) Multi-method study of Wraparound fidelity (comparisons across fidelity measures)
Impact of Training and Technical Assistance (IOTTA) Measure Perceptions of training and TA, predictors of practice change, barriers to change, intended and follow-up impact of training/TA Validation study of the IOTTA; study to examine characteristics of training and TA that predict practice changes
Intervention Usability Scale (IUS) Perceived utility of specific interventions Validation study of the IUS
Wraparound Implementation Standards – System and Program (WISS and WISP) Progress on getting system- and program-level practices in place to support Wraparound implementation Impact of inner and outer setting factors on Wraparound implementation quality
Stages of Implementation Completion (SIC) Implementation processes tracked over time Examination of factors that influence time to Wraparound implementation completion

New National Institute of Mental Health Grant Supports Development and Testing of Text-Based Outcomes Monitoring System for Wraparound

May 13, 2022 | Eric Bruns

Multiple research studies have documented the potential for positive effects of routine outcomes monitoring (ROM) in health care and behavioral health services.

Defined as “session-to-session measures of client progress to evaluate and improve treatment outcome,” ROM is also a core component of Wraparound care coordination as trained and supported by the National Wraparound Implementation Center (NWIC) and others.

At every Wraparound meeting, for example, the team should review and/or collect data on the family’s own rating of progress toward meeting their priority need(s) and vision for the future. Collecting such information can reinforce when recognizable progress is being made or highlight elements of a plan of care that need to be revised. ROM can improve the alliance among Wraparound team members, aid in supervision, and help a Wraparound provider organization be alerted when a youth, caregiver, or family is “off track” or experiencing an otherwise unknown crisis. Furthermore, when aggregated, such data can help identify provider organizations or other units that are achieving positive outcomes – or need attention to improve the quality of their care.

As described in this wonderful review by some of the world’s leading researchers on ROM, however, significant barriers impede actual implementation of ROM. Barriers include financial burdens, time burdens, competing stakeholder needs, and staff turnover, among many others.

In Wraparound, even though being “outcomes-based and data informed” may be our most important principle, our experience indicates consistent collection of progress and process data is rare. Fidelity data confirm this problem.

In an attempt to overcoming practical barriers to ROM in Wraparound, the University of Washington Wraparound Evaluation and Research Team (UW WERT) has partnered with 3C Institute on a recently awarded grant to develop and test a “mobile Routine Outcomes Monitoring” (mROM) system specific to Wraparound.

The proposed SMART-Wrap (Short Message Assisted Responsive Treatment for Wraparound) product will use brief prompts sent by text that can be read and responded to in a matter of seconds. Data would then be sent securely to a dashboard linked to UW WERT’s WrapStat system for review by the family’s care coordinator and others responsible for providing effective Wraparound support. If necessary, the system will send alerts to helpers, which could be when a family is in trouble or not making progress, or when progress and/or positive outcomes should be celebrated.

Given that 90% of text messages are opened within three seconds of their receipt, our hope is that “SMART-Wrap” may serve as a way to reduce the cost, time, and logistical barriers to getting actionable, “real-time” information from caregivers and youth to inform teamwork, plan of care revisions, supervision, and program evaluation.

Over the course of four phases of work, this project will:

  1. Get input on SMART-Wrap system functionality from parents/caregivers, young people, Wraparound providers, mROM researchers, and other experts;
  2. Develop an initial SMART-Wrap prototype;
  3. Test out SMART-Wrap usability and feasibility with a small number of programs and enrolled families;
  4. Prepare for a larger test of the system, incorporation into WrapStat, and dissemination to the field.

As some may remember, a survey of the National Wraparound Initiative community of practice in 2020 informed the original NIMH grant and demonstrated interest among Wraparound initiatives nationally. Now that it has been awarded, we plan to continue to inform and engage Wraparound experts nationally as we use NIMH funds to develop and test SMART-Wrap over the next 18 months.

If your Wraparound Provider Organization or initiative is interested in participating in this project in some way, please do not hesitate to contact UW WERT at wrapeval@uw.edu.

As always, we are grateful to be part of a national movement to provide effective care to youth with the most complex needs and their families. We hope this project will be yet another successful undertaking that advances Wraparound and its positive impact.

Wraparound Care Coordination Added to Inventory of Programs in Prevention Services Clearinghouse

January 28, 2022 | Eric Bruns

On January 25, “Intensive Care Coordination Using a High Fidelity Wraparound Process” (i.e., Wraparound or High Fidelity Wraparound) was added to the inventory of research-supported programs listed in the Prevention Services Clearinghouse.

The Clearinghouse was established by the Administration for Children and Families (ACF) to systematically review research and evaluation on programs and services intended to provide enhanced support to children and families involved in child welfare systems and prevent foster care placements. The goal of the Clearinghouse is to provide an objective source of information on evidence-based programs and services that may be eligible for funding under Title IV-E of the Social Security Act as amended by the Family First Prevention Services Act (FFPSA).

Following an approach required by statute, the Clearinghouse rates programs and services determined to have some level of research support as “Well-supported,” “Supported,” or “Promising.” Programs also can be evaluated as “Not Meeting Criteria” for research support.

In characterizing “the extent of evidence for the program or service,” Wraparound received a rating of “Promising.”

How Did the Clearinghouse Determine its Rating for Wraparound?

Promising programs are those whose research base is found to have “at least one contrast in a study that achieves a rating of moderate or high on study design and execution and demonstrates a favorable effect on a target outcome.” By comparison, to achieve a rating of “Well-supported,” reviewers need to find two “contrasts” (i.e., significant differences between groups) in one or more rigorous studies (i.e., with “moderate or high study design and execution”) and at least one study with sustained favorable effect of at least 12 months beyond the end of treatment. To achieve a rating of “Supported,” at least one contrast (significant difference) is needed in a rigorous study and at least one with sustained favorable effect of at least 6 months beyond the end of treatment.

Wraparound has been determined by other inventories and scholars to be evidence-based, based on the strength of at least 17 controlled studies (as found in our recent meta-analysis). So why did the Clearinghouse make its determination of “Promising”? Several specific statutory requirements for the Clearinghouse review process likely played a part:

  1. First, given its focus on foster care and child welfare, the Clearinghouse only reviews studies where at least some proportion of participating youth were involved in the child welfare system. Because Wraparound is a model with broad applicability to youth with complex needs, many studies of Wraparound effectiveness were conducted in other child-serving sectors, such as mental health or juvenile justice.
  2. Second, to assure consistency in its review process across many dozens of programs, the Clearinghouse defined certain criteria for level of rigor of research studies. Studies that do not meet these criteria cannot be the basis on which programs are determined “Well supported” or “Supported.”

    One relevant criterion for “Supported” is that study designs cannot be found to have a “Substantially Different Characteristics Confound.” That is to say, characteristics of the experimental and comparison groups must not substantially differ from one another. Because Wraparound studies are almost always conducted in “real world” service systems, this is a difficult condition to achieve, even in randomized trials. For example, a quasi-experimental study by Pullmann et al., (2006) reviewed by the Clearinghouse found that Wraparound youth experienced fewer offenses post-enrollment than the comparison group. However, the Wraparound and comparison groups differed by average age of youth and number of offenses at baseline. Specifically, the Wraparound group was older and had more previous offenses. Thus, even though youth in the Wraparound groups were probably more likely to have future justice offenses, strengthening the finding of Wraparound’s effectiveness, the study design confound ran afoul of Clearinghouse criteria. Several other Wraparound studies reviewed by the Clearinghouse featured similar design features. Thus, despite their findings being more likely to generalize to the “real world” (and often providing greater evidence of Wraparound’s effectiveness), the nature of Wraparound studies conducted in authentic service systems may reduce their rating of rigor as per the criteria of the Clearinghouse.

  3. Finally, and perhaps most important, Clearinghouse criteria require durability of positive effects – 6 months post-discharge for “Supported” and 12 months post-discharge for “Well Supported.” Because Wraparound is focused on youth with very serious and complex needs and their families, enrollment periods are typically longer than interventions that focus on a more limited set of skills or goals. Furthermore, they vary in length, being individualized to the needs and progress of the youth and family. Thus, the durability of effect standard is more easily achieved for research on interventions that are brief and time-limited. Only one Wraparound study reviewed met both criteria for adequate rigor and assessed outcomes post-discharge (Coldiron et al., 2019). Unfortunately, this study was found to only assess outcomes 3 months (not 6 or 12 as required) post-discharge. Thus, in and of itself, this Clearinghouse standard probably meant that “Promising” was as good a rating as could be found for Wraparound, based on studies reviewed.

What Next?

Overall, the listing of Wraparound on the Prevention Services Clearinghouse is positive news. First, despite over 1,000 nominations of programs, Wraparound is one of only 50 or so to be listed in the Clearinghouse. Second, despite the above challenges of fitting its research base to the Clearinghouse criteria and process, Wraparound was found to be supported by evidence. Finally, states that seek to use Wraparound partly or wholly for its child welfare population now know of its status and what the rules are for including Wraparound in their Title IV-E plans.

Moving forward, there are two main implications of the Clearinghouse finding of “Promising” for Wraparound care coordination.

First, states that seek to fund Wraparound via Title IV-E will need to develop and describe a rigorous evaluation plan of Wraparound fidelity and outcomes. Because “Wraparound is worth doing well” (and often is not done well), we would argue such evaluation should be done with every large-scale Wraparound initiative. Wraparound also is implemented very differently in every state service system. As such, this requirement is far from unreasonable. Furthermore, the field now has a greater array of strategies for continuous quality improvement and evaluation than ever. These include fidelity measures (such as the Wraparound Fidelity Assessment System) and web-based software (such as the WrapStat system) that support rigorous evaluation of fidelity and outcomes. Also, states that organize their systems of care and Wraparound initiatives via care management entities (CME) will have additional, research-based methods to collect and use data that can meet FFPSA / Title IV-E criteria.

Second, now that we know what is lacking in the Wraparound evidence base (at least per criteria of the Clearinghouse), we also now know what we need to do to improve Wraparound’s Clearinghouse research support rating. States that choose to invest in Wraparound may consider seeking opportunities to partner with researchers to conduct evaluations with adequate rigor to meet Clearinghouse standards, such as by comparing Wraparound outcomes to comparison groups of similar youth, and collecting youth outcomes data at least 6 months post-transition. Although such levels of evaluation rigor won’t be necessary or possible in all state Wraparound rollouts, we should work together to find such opportunities where possible.

In the coming weeks, the NWI will issue further blogs and updated guidance documents on how Wraparound-implementing states can meet requirements for FFPSA evaluation plans, and tools and systems that can support evaluation. While the finding of Wraparound as “Promising” on the Clearinghouse may feel like mixed news, this news also provides clarity on next steps and an array of new, exciting challenges for us to work together to achieve.

“Can We Finally Call Wraparound Evidence-Based?”

November 4, 2021 | Eric Bruns

On November 1, 2021, the recently completed meta-analysis of effects of Wraparound care coordination was included as a “spotlighted” article in the print edition of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP). Authored by Jonathan Olson, Eric Bruns, and others with the University of Washington Wraparound Evaluation and Research Team, this research study found that Wraparound consistently produces more positive outcomes than services as usual for youths with serious and complex needs, particularly for youth of color. The article is available for free and downloadable in full from the Journal’s website.

The November print edition of JAACAP also included a companion editorial by Dr Justine Larson, MD, MPH, entitled “Can We Finally Call Wraparound Evidence-Based for Youths with Serious Emotional Disorders?” Dr. Larson argues that “No greater obligation exists for child and adolescent psychiatrists than understanding how to take care of the most complex youths—those with serious emotional disorders (SEDs), co-occurring conditions, and multi-system involvement.”

Dr. Larson goes on to conclude that the results of the meta-analysis reinforce what many in the field have long known, that the heterogeneity and complexity of youths with serious emotional and behavioral challenges requires use of a comprehensive approach to service coordination and delivery that is “best suited to the population,” specifically, “a structure or process for planning intervention(s), as opposed to one specific intervention.” She goes on to write that “the review by Olson et al. provides further support for Wraparound as an evidence-based intervention,” and that “children and adolescents with SEDs are complex, with multiple diagnoses and psychosocial challenges requiring complex, multi-component intervention; Wraparound is the process that can organize the treatment.”

Given the findings that studies with higher rates of youth of color showed significantly greater effects, Dr. Larson concludes by stating “It is a matter not only of science but of equity to further study such interventions that seem particularly effective for youths of color.”

At the same time, Dr. Larson notes that “the quality and approach of Wraparound programs can vary significantly by community,” and that “measures of fidelity and implementation standards do exist, but the use of such measures in research and community practice is inconsistent.”

We could not agree more with all the above points made by Dr. Larson. Investment in community-based models such as Wraparound (as well as mobile crisis services, parent and youth peer support, respite, and intensive in-home treatment) should all be viewed as “obligations” of public systems. But these models must be implemented with quality and fidelity, and supported by coaching, technical assistance, and data at multiple levels. As noted in another recent empirical study by the research team, the conditions present in states, systems, and provider organizations must be hospitable to achieve fidelity to research-based standards as well as positive youth and family outcomes.

We also wholeheartedly agree that continued examination of Wraparound effects for youth and families from different backgrounds holds promise to not just inform Wraparound development and implementation, but the field of child, youth, and family behavioral health as a whole.

In her editorial, Dr. Larson muses, “What is the ‘special sauce’ that makes Wraparound effective? To use a pharmacological analogy, Wraparound can be thought of as acting on multiple receptors affecting the youths and family—engagement challenges, psychosocial issues, as well as specific treatment targets with specific interventions… the mechanisms of action resulting in wraparound’s effectiveness involve both family engagement and appropriate tailoring of interventions.”

For public systems to actualize this theory requires unwavering attention to quality of implementation. With Wraparound’s potential for positive effects now known, the field can turn fully to the true challenge, which is assuring that Wraparound lives up to that potential in every state and service system in which it is deployed.

Research Supports Expanding Telehealth for Systems of Care: What Does Your Experience Say?

October 17, 2021 | Janet Walker

The COVID-19 pandemic in the United States created a public health emergency that led to an unexpected and enormous increase in the use of telehealth strategies to deliver behavioral health services. As the pandemic ebbs, temporary emergency policies expanding the use of telehealth will expire. Now, policymakers and other stakeholders are considering the extent to which policies expanding telehealth should be made permanent. Without proactive efforts, it’s likely that options for using telehealth in systems of care will be significantly reduced.

Instead of retreating from telehealth in systems of care, research evidence suggests we should be focused on figuring out the best ways to expand it further. This is particularly important given existing workforce shortages. Shortages were already acute in public mental health systems prior to the pandemic, and they are currently at crisis levels in many parts of the country. Given the positive findings from research, it seems like a bad idea to reduce use of a technology that has been shown to have the potential to make mental health services more efficient, equitable and effective.

The paragraphs below provide a summary of the research evidence and expert consensus in support of continuing to expand the use of telehealth strategies in systems of care for youth, young adults, children and families. But research studies paint only part of the picture. We invite you to share your experiences and opinions on telehealth in this short NWI telehealth survey. We’ll let you know what we find out!

Share your opinions and experiences providing or receiving services/supports via telehealth by taking the 3-minute NWI telehealth survey.

Prior to the pandemic, a number of systematic reviews of available research compared telehealth with in-person visits. Systematic reviews are a formal way to combine findings from multiple studies on the same topic, and to draw conclusions about what the studies say when taken as a group. Recent systematic reviews of telehealth research are based on as many as 1,500 individual studies. These reviews have found telehealth to be at least as effective as in-person visits, with one review saying that “Telehealth interventions produce positive outcomes… for psychotherapy as part of behavioral health,” and another review saying that “Studies examining telemental health services generally found that outcomes did not differ significantly from in-person intervention.” Another systematic review focused specifically on telehealth for family mental health services, and found that family therapy outcomes for “child behavioural problems… showed equivalent outcomes in telehealth and face-to-face therapy.”

During the pandemic, the shift to telehealth was in many cases unplanned and somewhat chaotic; however, expert consensus and emerging research conclude that the forced experiment with telehealth was generally successful. For example, one study found that “… the no-show rate of telehealth visits during the COVID-19 pandemic was… lower than both the no-show rate for in-office visits and a pre-pandemic in-office no-show rate,” while satisfaction was similar. A study of a first-episode of psychosis program found that “The no-show rate during the shelter-at-home period was 28 percent, compared to 32 percent the previous year.”

This year, as the pandemic passed the one-year mark, SAMHSA released an expert consensus report endorsing telehealth, saying “Telehealth is effective across the continuum of care for SMI [serious mental illness] and SUD [substance use disorders], including screening and assessment, treatments, including pharmacotherapy, medication management, and behavioral therapies, case management, recovery supports, and crisis services.” Similarly, a 2021 policy brief from the Child Health and Development Institute of Connecticut focused on delivery of behavioral health services for children and families. The policy brief concludes that research “has shown telemedicine to generally be as effective as in-person psychotherapy for a range of diagnoses modalities, and for children, adolescents, and adults.”

The Connecticut policy brief also noted that telehealth “has reduced or eliminated common barriers to care such as non-emergency medical transportation, two-parent work schedules, lack of child care options, and the stigma that can be associated with visiting a behavioral health clinic. Support of telemedicine is grounded in its powerful potential to promote better and more equitable access, engagement, and outcomes, particularly among traditionally underserved populations.” Other studies assess the benefits of telehealth for behavioral health services similarly, focusing on its potential to address barriers related to transportation, poverty and stigma. Further, telehealth can expand access to providers with particular areas of expertise and success in working with populations that are underserved and/or that are less likely to be engaged in services.

The potential drawbacks of telehealth for behavioral health participants are well known, and include lack of access to high-speed internet, lack of appropriate devices, and difficulty finding private space to participate in telehealth services. Additionally, more research is needed to explore in detail best practices for telehealth at the policy level, as well as at the organizational and individual provider levels. Yet even with these challenges remaining, it seems clear that telehealth should remain widely available as an option while research continues to explore its enormous potential to improve systems of care.

Share your opinions and experiences providing or receiving services/supports via telehealth by taking the 3-minute NWI telehealth survey.

New Report from WERT Provides Benchmarks for the WFI-EZ

August 30, 2021 | Janet Walker

Users of the Wraparound Fidelity Index-EZ will be pleased to learn that the Wraparound Evaluation and Research Team at the University of Washington has released a brief report describing benchmarks that programs can use to interpret their WFI-WZ scores.

The benchmarks provide score ranges for Wraparound fidelity that is high, adequate, borderline and inadequate. Benchmarks are provided for the overall fidelity score, as well as scores in five sub-areas assessed by the WFI-EZ: outcomes based, effective teamwork, natural supports, needs based, and strength and family driven. Benchmarks are also provided for overall satisfaction. Different benchmarks are provided for interpreting scores from the youth and family forms, and from the care coordinator and other team member forms.

Access the benchmarks report »

Wraparound Implementation in Care Management Entities Tends to be Better than Implementation in CMHCs

May 9, 2021 | Janet Walker

Wraparound care coordination has been implemented throughout the United States to help support youth with serious emotional and behavioral needs and their families. A recent meta-analysis of 17 controlled studies found that young people who participate in Wraparound are more likely to stay in their homes and communities, and they experience better outcomes in the areas of mental health symptoms, mental health functioning, and school functioning when compared to youth receiving traditional mental health services.

With Wraparound now clearly recognized as a research-based strategy, states and jurisdictions need guidance on how to optimally support high-quality implementation via policy and funding strategies. A new study by a team of researchers at the University of Washington Department of Psychiatry and Behavioral Sciences has identified several conditions that can help promote high quality implementation of Wraparound. Using data drawn from a sample of more than 1000 Wraparound providers from 9 states, the study examined the influence of specific policies, administrative structures, and characteristics of provider organizations on the quality of Wraparound implementation.

Global Implementation Research and ApplicationsGlobal Implementation Research and Applications

The study, published in Global Implementation Research and Applications, found that implementation was consistently better when Wraparound was administered through Care Management Entities (CMEs) as compared to more traditional Community Mental Health Centers (CMHCs). CMEs tend to employ practitioners that specialize in care coordination, and what is more, states that invest in CMEs typically provide them with more flexible financing arrangements (such as case rates) and allow them to contract with a wide array of providers to allow for a more diverse array of services for the youth and families enrolled in Wraparound.

The study found that care coordinators employed by CMEs demonstrated better implementation outcomes, such as higher levels of skill in the Wraparound model and more Wraparound-related professional development trainings, compared to CMHC-employed care coordinators. States using CMEs also were able to get to full implementation of Wraparound faster than states using CMHCs to provide Wraparound.

These findings are not entirely surprising given that CME structures allow for greater flexibility and coordination of care. They are specifically designed to engage multiple systems to support youth by offering a more flexible case rate, employing providers who specialize in care coordination, and creating processes that promote individualized care for young people and their families.

The findings of this study have important implications for organizations interested in implementing Wraparound. One obvious implication of this research is that those interested in implementing Wraparound would be well-served by employing CME structures. However, since state policy can be very difficult to change, states could also seek to emulate characteristics of CMEs. For example, more traditional mental health provider organizations could establish dedicated care coordination units with specialized supervision, be reimbursed via case rates to allow flexibility, and work with other agencies to diversify the service array available to these families, rather than just refer to services provided by their organization.

New Systematic Review Shows Wraparound to Be Effective, Particularly for Youth of Color

April 12, 2021 | Janet Walker

For nearly 30 years, “Wraparound” has been adopted in states and jurisdictions across the country to better meet the mental health and other needs of children and adolescents with serious emotional and behavioral needs and their families, and to keep them safely in their homes and communities. However, it has long been debated whether Wraparound is actually more effective than traditional services.

Journal of the American Academy of Child and Adolescent PsychiatryJournal of the American Academy of Child and Adolescent Psychiatry

A new research article, published in the Journal of the American Academy of Child and Adolescent Psychiatry and downloadable in full from the Journal’s website, finds that Wraparound does consistently produce more positive outcomes for these youth. Moreover, Wraparound may hold potential for reducing disparities in outcomes for youth of color, disparities that have long been found for mental health services.

Using a widely-used technique known as “meta-analysis,” a team led by Jonathan Olson, Ph.D., an NWI-affiliated Research Scientist at the University of Washington, examined the results of 17 controlled studies published between 1996 and 2019 that compared the effects of Wraparound to services as usual for similar youth with “serious emotional and behavioral disorders.”

The study found significant effects in favor of Wraparound across a range of important youth outcomes – including reduced out-of-home placements, improvements in mental health functioning, and better school attendance and achievement. The study also found significantly lower overall costs of care for youth in Wraparound, due to less spending on costly out-of-home placements. Across the 17 studies, Wraparound effects were more positive for samples with higher proportions of youth of color.

“For many years, public systems have used Wraparound because it makes sense and provides families with the kind of compassionate approach they say they want and need,” said Eric Bruns, Professor of Psychiatry and senior author on the research team. “Now we have clear evidence that Wraparound is also more effective and cost-effective than traditional services.”

Wraparound was innovated in the 1980s as an alternative to service delivery strategies that were driven by professionals and forced families to navigate complex systems and services on their own. When families became overwhelmed and/or failed to get their needs met, costly institution-based care was often the result.

Instead, Wraparound invests in a care coordinator with low caseloads who convenes a team that includes the family’s friends and natural supports, as well as professionals. “Wraparound lives up to principles we want to uphold – for example, being youth- and family-driven, strengths-based, and using a team of people with a blank checkbook to ‘do whatever it takes’ to meet the needs of the youth and family,” said Bruns. “While many states have taken Wraparound to scale, others have been more hesitant, saying it wasn’t ‘evidence-based.’ This study should help address those concerns.”

Olson points out, however, that the study also reinforced how important it is to implement Wraparound with quality, and in a way that is true to the model.

“Unfortunately, many studies were conducted before there were measures of fidelity, or measures of ‘doing Wraparound right,'” said Olson. “However, for studies that did measure fidelity, we saw more positive outcomes for youth and families who received care that was of high-quality and closely adhered to Wraparound principles.”

Bruns said that the finding related to the potential for Wraparound to better meet the needs of youth of color was unexpected, but perhaps not surprising.

“We need to remember that in all these studies, Wraparound was compared to more traditional mental health, child welfare, and juvenile justice services,” Bruns said. “And there is a long history of research showing disparities in access and outcomes for youth of color and their families in such systems. It may be that by allowing for more youth and family voice and choice, and teams that include family, friends, and community members, Wraparound helps reduce those disparities.”

Bruns emphasized, however, that such questions were not an explicit focus of the new meta-analysis, or of the studies that were reviewed. “In Wraparound and youth services in general, we need to continue to research what may address racial and other disparities in outcomes with greater rigor.”

News from Alaska shows the need to recommit to Wraparound principles

February 8, 2021 | Janet Walker

A series of recent articles in the Alaska News provides a sobering update to the story of a program that was one of the first to show success from the use of a Wraparound-type approach. In 1985, stakeholders from Alaska’s social services, mental health, and education departments formed the Alaska Youth Initiative. The AYI—managed by Wraparound pioneer John VanDenBerg–was successful in returning to Alaska almost all youth with high levels of mental health needs who had been placed in out-of-state institutions. At that time, Wraparound had yet to be defined or formalized, but the AYI work was firmly rooted in the key principles of individualization, unconditional care, and increasing family voice and choice. The documented success of the Alaska Youth Initiative was a key factor in the subsequent evolution and popularization of Wraparound.

The history of Wraparound since the AYI provides many examples of growth and success. A range of initiatives have demonstrated the positive outcomes that occur when Wraparound is done well, and collectively we have created an abundance of tools and resources to support that work. And yet, 35 years after the AYI, the Alaska News articles show that maintaining progress is not guaranteed. The most recent article reports that Alaska’s justice department has opened an investigation into whether the state unnecessarily institutionalizes children with behavioral health conditions, focusing on the high number of Alaska children who are sent to (mostly) for-profit, locked psychiatric treatment facilities in distant states. One earlier article detailed the wide fluctuations in the number of children being sent out of state since 2000, while another article featured the stories of young people who had been sent out of state, and their experiences being separated from their home communities. Thanks in part to lobbying by these young people, the state is feeling pressure recommit to community-based care. With the recent developments, improvements may be coming in Alaska, but the state’s experience is a cautionary tale about the ongoing work that may be needed to maintain the successes that Wraparound initiatives have produced.

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